1225150980 NPI number — MRS. VIDA LYNNE PENN-LEON LCSW-C

Table of content: MRS. VIDA LYNNE PENN-LEON LCSW-C (NPI 1225150980)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225150980 NPI number — MRS. VIDA LYNNE PENN-LEON LCSW-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PENN-LEON
Provider First Name:
VIDA
Provider Middle Name:
LYNNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225150980
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/15/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1631 WESEL BLVD # 1047
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAGERSTOWN
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21740-5387
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-458-5199
Provider Business Mailing Address Fax Number:
240-337-8598

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
917 HOFFMASTER RD # MD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21758-1216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-458-5199
Provider Business Practice Location Address Fax Number:
240-337-8598
Provider Enumeration Date:
04/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  10379 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X , with the licence number: 0904015550 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: SWB-2024-0703 . This is a "LCSW-STATE LICENSE NM" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 115112 . This is a "LCSW - TEXAS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0904015550 . This is a "LICENSED CLINICAL SOCIAL WORKER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 10379 . This is a "LCSW-C" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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